The purpose of this rule is to
identify a subpopulation of persons determined to require an intermediate care
facility level of care whose care needs are not adequately measured by the
individual assessment form or by the resident assessment classification and
case mix payment system described in rule
5123:2-7-20 of the
Administrative Code.

(B)
For the purposes
of this rule, the following definitions shall apply:

(1)
"Designated
outlier coordinator" means a designated department staff member who coordinates
the general operations of the intermediate care facility outlier program. The
designated outlier coordinator works with providers of outlier services,
individuals and other persons whom individuals have identified requesting and
receiving outlier services, other service agencies, and other department staff.
The designated outlier coordinator's duties include, but are not limited
to:

(2)
"Individual plan" means a written description of the services to be provided to
an individual, developed by an interdisciplinary team that represents the
professions, disciplines, or service areas that are relevant to identifying the
individual's needs, as described by the comprehensive functional
assessments.

(3)
"Intermediate care facility for pediatric ventilator
services" means a facility that holds an effective intermediate care facility
provider agreement with the Ohio department of medicaid and that is approved by
the department to deliver outlier services to individuals under twenty-two
years of age who are dependent on invasive mechanical
ventilators.

(4)
"Invasive mechanical ventilator" means a ventilator
that is interfaced directly with the individual via an artificial airway (e.g.,
tracheostomy tube). Invasive mechanical ventilators (volume and/or pressure)
are life support devices designed specifically for invasive mechanical
ventilation applications and must accommodate direct current backup power
supply and include disconnect, high pressure, low pressure, and power loss
alarms.

(5)
"Level of care review" means the evaluation of an
individual's physical, mental, and social/emotional status to determine the
level of care required to meet the individual's service needs and includes
activities necessary to safeguard against unnecessary utilization. Level of
care determinations are based upon the criteria regarding the amount and type
of services needed by an individual that are set forth in Chapter 5101:3-3 of
the Administrative Code.

(6)
"Outlier services" means those clusters of services
that have been determined by the department to require reimbursement rates
established pursuant to section
5124.152 of the Revised Code
when delivered by qualified providers to individuals who have been
prior-authorized for the receipt of a category of service identified as an
outlier service by the department as set forth in Chapter 5123:2-7 of the
Administrative Code.

(7)
"Physician" means a doctor of medicine or osteopathy
who is licensed to practice medicine.

(8)
"Plan of
correction" means a corrective action plan prepared by an intermediate care
facility in response to deficiencies cited by the department or the Ohio
department of health. The plan shall conform to regulations and guidelines, and
shall include information that describes how the deficiency will be corrected,
when it will be corrected, how other residents that may be affected by the
deficiency will be identified, and how the facility will ensure that compliance
will be maintained upon correction.

(9)
"Prior
authorization assessment for intermediate care facility pediatric ventilator
services" means an evaluation to determine if an individual meets the criteria
to be served by an intermediate care facility for pediatric ventilator services
as outlined in paragraphs (C)(3) to (C)(7) of this rule, and shall take place
only after the individual is determined to meet the financial eligibility and
level of care requirements set forth in paragraphs (C)(1) and (C)(2) of this
rule.

(10)
"Prior authorization for intermediate care facility
pediatric ventilator services" means department approval obtained by an
intermediate care facility for pediatric ventilator services on behalf of a
specific individual for specific time-limited initial or continued stay periods
at the intermediate care facility for pediatric ventilator services. Prior
authorization for intermediate care facility pediatric ventilator services
shall be required for the provider to be authorized by the department to
receive reimbursement for services rendered to the individual. Reimbursement
may be denied for any service not rendered in accordance with Chapters 5101:3-3
and 5123:2-7 of the Administrative Code.

In the case of requests for continued
stay, the prior authorization for intermediate care facility pediatric
ventilator services shall occur no later than the final day of the previously
authorized intermediate care facility for pediatric ventilator services
stay.

The individual shall have obtained a
level of care determination from the department within the last thirty days,
or, at the time of prior authorization assessment for intermediate care
facility pediatric ventilator services, be determined by the department to meet
the criteria for a level of care as set forth in rule 5101:3-3-07 of the
Administrative Code.

(a)
The individual shall have been an inpatient, for at
least ninety days within the past twelve months, in an acute care hospital for
treatment of a life-threatening or complex medical condition and has needs,
specifically including invasive mechanical ventilation, that cannot be met by
services available in a non-institutional setting; or

(b)
The individual
resides at an intermediate care facility on the effective date of this rule and
has needs, specifically including invasive mechanical ventilation, that cannot
be met by services available in a non-institutional setting.

Prior to enrollment as an intermediate
care facility for pediatric ventilator services, and at regular intervals
thereafter, the department shall determine whether the intermediate care
facility for pediatric ventilator services provider qualifications are
fulfilled through review of documentation of appropriate policies and
procedures, on-site visits, and other mechanisms. In order to be approved as an
intermediate care facility for pediatric ventilator services and qualify for
enhanced payment for provision of intermediate care facility pediatric
ventilator services to prior-authorized individuals, a provider shall meet all
of the following criteria:

(b)
Meet the
medicaid program requirements of a facility for which the Ohio department of
health found deficiencies, have an approved and implemented plan of correction,
and have not demonstrated a pattern of repeat deficiencies.

(a)
The intermediate care facility shall have an emergency
action plan in place in the event of a power failure.

(b)
The intermediate
care facility shall have on-site backup generator service for all equipment
including suction lines, oxygen lines, and emergency power to
ventilators.

(c)
The intermediate care facility shall have sufficient
backup ventilators on-site and available in the event of mechanical failure as
well as any other equipment necessary to meet the needs of individuals in the
event of an emergency.

(d)
The intermediate care facility shall have an emergency
response plan in place in the event of natural or human-made disasters that
provides for the safe transport of individuals to a safe area with appropriate
resources available to ensure the health and safety of the
individuals.

Providers shall schedule direct care
staff to ensure that adequately trained staff are present and on duty seven
days per week, twenty-four hours per day, every day of the year. Staffing shall
be sufficient to ensure that urgent, emergent, and routine resident needs are
identified appropriately and in a timely manner and are met through the
implementation of intervention strategies reflected in the resident's
individual plan. Absences of staff for breaks and meals shall not compromise
this requirement.

Staff training programs shall address
the specific medical domains a staff member must master for a thorough
understanding and demonstration of competency in order to meet the specialized
needs of residents requiring intermediate care facility pediatric ventilator
services. Initial and continuing direct care staff training shall include all
of the following:

(i)
Orientation to the facility's status as a provider of
intermediate care facility pediatric ventilator services, including the
individual eligibility criteria outlined in paragraph (C) of this rule and the
provider eligibility criteria outlined in paragraph (D) of this
rule;

(ii)
Information about the disorders and diseases affecting
the current residents of the intermediate care facility pediatric ventilator
services provider;

(iv)
Training to ensure nursing care competence for
patients under twenty-two years of age, including specialized training on
developmental needs that improve an individual's overall functional status;
and

(v)
Due to the increased risk of infection for residents
of intermediate care facilities for pediatric ventilator services, staff
training shall include steps to be taken to minimize risk of transmission of
contagious or infectious diseases.

The provider shall agree to furnish or
arrange to have furnished all medically necessary services to individuals who
are dependent on invasive mechanical ventilators, regardless of whether the
services are reimbursable through the intermediate care facility cost report
mechanism or directly to the provider of such services.

(a)
The facility
shall ensure that physician services are available twenty-four hours per
day.

(b)
A physician shall complete an assessment of the
individual at least once every thirty days for the first ninety days and at
least once every ninety days thereafter if the individual maintains a stable
status with no acute complications related to ventilator support. If acute care
needs requiring hospitalization present upon return to the intermediate care
facility for pediatric ventilator services, a physician shall complete an
assessment of the individual at least once every thirty days for the first
ninety days and at least once every ninety days thereafter.

(c)
The facility
shall ensure that licensed respiratory care practitioner services are available
twenty-four hours per day. Medically necessary respiratory care services shall
be provided by a licensed respiratory care practitioner and/or by a nurse, who
the facility has determined has the training, knowledge, skill, and ability to
complete the services in coordination with the licensed respiratory care
practitioner, and as ordered by a physician.

(d)
The facility, in
consultation with a physician and a licensed respiratory care practitioner,
shall develop a facility plan for providing care to individuals who are
dependent on invasive mechanical ventilators. The plan shall address
maintenance of ventilators, required modification and maintenance of
facilities, and special accommodations required to ensure that all needs,
including but not limited to, hygiene, bathing, dietary, social, and
transportation, of individuals who are dependent on invasive mechanical
ventilators, are met.

(e)
The facility shall ensure that registered nursing
services are available twenty-four hours per day.

(f)
Nursing care and
any personal care that may be required for the health, safety, and wellbeing of
the individuals served shall be available twenty-four hours per day. Nursing
personnel shall be sufficient to ensure prompt recognition of any adverse
change in an individual's condition and to facilitate nursing, medical, or
other appropriate interventions, up to and including transfers to an acute care
hospital.

(g)
The need for physical, occupational, and/or speech
therapy services shall be assessed and services shall be provided as
needed.

(h)
If an individual is receiving enteral feedings and
there is a complication of medical status secondary to the nutritional status,
a dietary consultation shall be made available to that
individual.

Prior to an individual's admission to
an intermediate care facility for pediatric ventilator services, the provider
shall arrange for a suitable school or day program for the individual and shall
submit the plan for such program to the designated outlier coordinator or other
department designee.

(a)
Prior to an individual's admission to an intermediate care facility for
pediatric ventilator services, the provider shall develop and submit to the
designated outlier coordinator or other department designee accurate
assessments or reassessments by an interdisciplinary team that address the
individual's health, social, psychological, educational, vocational, and
chemical dependency needs.

(b)
Health
information shall include a copy of the medical assessment completed by a
pediatric physician who has knowledge of and experience with the individual and
shall include a clinical summary, need for invasive mechanical ventilation
(including viability and plan for weaning), detailed therapy assessment with
recommended therapy plan, medication needs, and any other medical information
relevant to the individual's care needs.

A registered nurse shall submit a
written summary of clinical status to the primary care physician on a monthly
basis. The physician shall review and sign the summary and place it in the
individual's medical record.

Due to the complex and intensive needs
of individuals being admitted to an intermediate care facility for pediatric
ventilator services, the provider shall develop a transitional plan prior to
admission of an individual to ensure that the facility is able to meet the
individual's health, safety, and behavioral needs from the day of admission.
The transitional plan shall address major concerns and shall be provided to the
designated outlier coordinator or other department designee upon
request.

Within thirty days after admission,
the provider shall develop accurate assessments or reassessments by an
interdisciplinary team that address the individual's health, social,
psychological, educational, vocational, and chemical dependency needs in order
to supplement the preliminary evaluation described in paragraph (D)(9) of this
rule, which was conducted prior to admission. The provider shall provide the
assessments or reassessments to the designated outlier coordinator or other
department designee upon request.

(a)
Within thirty
days of an individual's admission, the facility, with input from the
individual, the individual's parent, the individual's guardian, or other person
whom the individual has identified, as applicable, shall develop a
comprehensive individual plan. The individual plan shall be reviewed by the
appropriate program staff at least quarterly and revised as necessary with
input from the individual, the individual's parent, the individual's guardian,
or other person whom the individual has identified, as applicable. The facility
shall provide a copy of the individual plan to the designated outlier
coordinator or other department designee upon request.

(b)
The facility
shall notify the designated outlier coordinator or other department designee
whenever an individual experiences a significant change in medical status,
including hospitalization.

(c)
The facility
shall prepare a quarterly report in a format approved by the department that
summarizes the resident's individual plan, progress, changes in treatment,
current status relative to discharge goals, and any updates to the discharge
plan, including referrals made and anticipated time frames. The facility shall
provide a copy of the quarterly report to the designated outlier coordinator or
other department designee upon request.

(d)
The designated
outlier coordinator or other department designee may visit the facility at any
time. The facility shall provide any documents or information requested by the
designated outlier coordinator or other department designee.

Within thirty days after admission,
the facility shall develop a written discharge plan developed by the
interdisciplinary team in conjunction with the individual and others concerned
with the individual's welfare. The discharge plan shall include a description
of targeted medical/health status indicators that would signify the resident
could be safely discharged. The facility shall provide a copy of the discharge
plan to the designated outlier coordinator or other department designee upon
request

If prior authorization is denied
during an assessment that was requested for an individual already residing in
the intermediate care facility for pediatric ventilator services, the
intermediate care facility shall accept payment for the provision of services
at the non-outlier intermediate care facility reimbursement rate.

(a)
A facility per diem rate shall be set in accordance
with Chapter 5124. of the Revised Code and applicable rules in Chapter 5123:2-7
of the Administrative Code. An outlier per diem rate add-on for pediatric
ventilator services, determined and applied in accordance with paragraph (H) of
this rule, shall be added to the facility per diem rate.

(b)
With the
exception of any specific items that are direct-billed in accordance with rule
5123:2-7-11 of the
Administrative Code, the provider shall agree to accept as payment in full the
per diem rate established for intermediate care facility pediatric ventilator
services in accordance with this rule, and to make no additional charge to the
individual, to any member of the individual's family, or to any other source
for covered intermediate care facility pediatric ventilator
services.

Payment for intermediate care facility
pediatric ventilator services covered by the medicaid program shall be
available only upon prior authorization by the department for each individual
in accordance with the procedures set forth in this rule. The prior
authorization procedures set forth in this rule are in addition to the level of
care review process set forth in rule
5123:2-7-06 of the
Administrative Code.

It is the responsibility of the
provider to ensure that all required information is provided to the department
as requested. An initial request for prior authorization for intermediate care
facility pediatric ventilator services is considered complete when all of the
following requirements have been met:

(a)
The Ohio
department of job and family services form 03142, "Prior Authorization"
(revised March 2008), has been appropriately completed and
submitted;

(b)
The Ohio department of job and family services form
03697, "Level of Care Assessment" (revised April 2003), or an alternative form
specified by the department that accurately reflects the individual's current
mental and physical condition and is certified by a physician has been
appropriately completed and submitted;

(c)
In accordance
with the level of care review process for intermediate care facilities set
forth in rule
5123:2-7-06 of the
Administrative Code, a level of care determination has been issued in
accordance with rule 5101:3-3-07 of the Administrative Code and a determination
regarding the feasibility of community-based care has been made;
and

(d)
The intermediate care facility for pediatric
ventilator services has submitted to the designated outlier coordinator the
prior authorization request form and supporting documentation exhibiting
evidence that the applicant meets criteria listed in paragraphs (C)(3) to
(C)(7) of this rule. The provider shall retain a duplicate copy of all
submitted documentation. Supporting documentation may include, but is not
limited to, the preliminary evaluation, assessments, and transitional plan
required prior to admission as set forth in paragraph (D) of this
rule.

The department's determination will be
based on the completed initial stay request and any additional information or
documentation necessary to make the determination of eligibility for
intermediate care facility pediatric ventilator services, which may include a
face-to-face visit by at least one department representative with the
individual and, if applicable, the individual's parent, the individual's
guardian, or other person whom the individual has identified and, to the extent
possible, the individual's formal and informal care givers, to review and
discuss the individual's care needs and preferences.

Based upon a comparison of the
individual's condition, service needs, and the requested placement site with
the eligibility criteria set forth in paragraph (C) of this rule, the
department shall conduct a review of the application, assessment report, and
supporting documentation about the individual's condition and service needs to
determine whether the individual is eligible for intermediate care facility
pediatric ventilator services.

When a request for prior authorization
for intermediate care facility pediatric ventilator services has been processed
by the department, the department shall issue a notice of determination
indicating approval or denial of the request by mail or fax to the individual,
the individual's parent, the individual's guardian, or other person whom the
individual has identified, as applicable, and the provider.

When a request for prior authorization
for intermediate care facility pediatric ventilator services is denied, the
department shall issue a notice of denial and the individual's right to a state
hearing in accordance with Chapter 5101:6-2 of the Administrative Code. The
notice shall include an explanation of the reason for the denial. The
department shall send a copy of the notice to the county department of job and
family services to be filed in the individual's case record.

When a request for prior authorization
for intermediate care facility pediatric ventilator services is approved, the
department shall issue an approval letter that includes an assigned prior
authorization number, the number of days for which intermediate care facility
pediatric ventilator services are authorized, and the date on which payment is
authorized to begin. The approval letter shall include the name, location, and
phone number of the department staff member who is assigned to monitor the
individual's progress in the facility. The department shall send a copy of the
approval letter to the county department of job and family services to be filed
in the individual's case record.

Individuals who are determined to have
met the eligibility criteria set forth in paragraph (C) of this rule may be
approved for an initial stay of up to a maximum of six months, or up to one
hundred eighty-four days. The number of months or days that is prior-authorized
for each eligible individual shall be based upon the submitted application
materials, consultation with the individual's attending physician, and/or any
additional consultations or materials required by the assessor to make a
reasonable estimation regarding the individual's probable length of stay in the
intermediate care facility for pediatric ventilator services.

Continued stay determinations shall be
based on reports from the facility submitted to the designated outlier
coordinator regarding critical events and the status of the individual's
condition and discharge planning options, face-to-face assessments conducted by
the department, and/or other information determined by the department. When the
department determines that the individual continues to meet the eligibility
criteria set forth in paragraph (C) of this rule, and the provider submits a
request for continued stay in accordance with paragraph (E)(6)(b) of this rule,
continued stays may be approved for maximum increments of six months, up to one
hundred eighty-four days.

(c)
Reimbursement
for services provided by an intermediate care facility for pediatric ventilator
services shall be limited to services approved as indicated in the approval
letter.

(a)
An individual is expected to be discharged to the
setting specified in the individual's discharge plan at the end of the
prior-authorized initial or continued stay, and progress toward that end shall
be monitored by the department or its designee throughout the individual's stay
in the intermediate care facility for pediatric ventilator
services.

(b)
Intermediate care facility pediatric ventilator
services may be extended beyond the previously approved length of stay if the
provider submits a written request to the department proving that it is not
possible to implement the individual's discharge plan. Such requests shall be
submitted at least thirty days prior to the last day of the previously
authorized stay, unless there is a significant change of circumstances within
the week preceding the expected discharge date that prevents implementation of
the discharge plan.

(F)
Application for
designation as a provider of intermediate care facility for pediatric
ventilator services

The payment authorization date shall
be one of the following, but shall not be earlier than the effective date of
the individual's level of care determination:

(1)
The date of
admission to the intermediate care facility for pediatric ventilator services
if it is within thirty days of the physician's signature on the Ohio department
of job and family services form 03697, "Level of Care Assessment" (revised
April 2003), or an alternative form specified by the department;
or

(2)
The date of intermediate care facility for pediatric
ventilator services prior authorization approval, if the individual was already
a resident of an intermediate care facility for pediatric ventilator services
but was using another payer source; or

(3)
A date other
than that specified in paragraph (G)(1) or (G)(2) of this rule. This
alternative date may be authorized only upon receipt of a letter by the
designated outlier coordinator or other department designee that contains a
credible explanation for the delay from the originator of the request for prior
authorization of intermediate care facility pediatric ventilator services. If
the request is to backdate the level of care and intermediate care facility for
pediatric ventilator services eligibility determination more than thirty days
from the physician's signature, the physician shall verify the continuing
accuracy of the information and need for inpatient care either by adding a
statement to that effect on the form 03697 or an alternative form specified by
the department, or by attaching a separate letter of
explanation.

The department shall establish the
initial and subsequent contracted rates in accordance with Chapter 5124. of the
Revised Code. All rate adjustments determined in accordance with this rule
shall be effective the first day of the first month following the admission or
discharge of an individual meeting the requirements set forth in this rule,
including prior authorization requirements set forth in paragraph (E) of this
rule.

(1)
An intermediate care facility for pediatric ventilator
services serving one individual meeting the requirements set forth in paragraph
(C) of this rule and prior-authorized for intermediate care facility pediatric
ventilator services shall be eligible for the outlier per diem rate add-on
using the following formula:

Divide three hundred dollars by the
number of licensed beds in the intermediate care facility including the bed
occupied by the individual receiving intermediate care facility pediatric
ventilator services. The result will be added to the facility's per diem
rate.

(2)
An intermediate care facility for pediatric ventilator
services serving more than one individual meeting the requirements set forth in
paragraph (C) of this rule and prior-authorized for intermediate care facility
pediatric ventilator services shall be eligible for the outlier per diem rate
add-on using the following formula:

Multiply the number of individuals
residing in the intermediate care facility prior-authorized to receive
intermediate care facility pediatric ventilator services by three hundred
dollars. Divide the product by the number of licensed beds in the intermediate
care facility including the beds occupied by the individuals receiving
intermediate care facility pediatric ventilator services. The result will be
added to the facility's per diem rate.

(3)
The amount of
the intermediate care facility pediatric ventilator services outlier per diem
rate add-on shall be recalculated when individuals eligible for intermediate
care facility pediatric ventilator services are admitted or discharged, when
individuals become ineligible, as well as during each rate-setting process for
the intermediate care facility. The provider shall be responsible for
contacting the designated outlier coordinator no later than by the close of the
next business day following the discharge of an individual to ensure processing
time for recalculation and application of the outlier per diem rate add-on to
the facility per diem rate.

(4)
If the
department obtains the ability to utilize person-specific rates, the outlier
per diem rate add-on will be specific to the individual approved to receive
pediatric ventilator services in the amount of three hundred
dollars.